Life Insurance Health Screening Questionnaire

Life Insurance Health Screening Questionnaire

Client Name: ______________________________________________________________________

Agent Name: ______________________________________________________________________

Proposed Death Benefit Amount: ______________________________________________________

Type of Policy Seeking: ______________________________________________________________

Life Insurance is about protecting the things that are important to your clients. When considering life insurance for your client,

you must think about their health. It is their health, not their pocketbook, that determines if life insurance makes sense.

Date of Birth: _______________________

Do you use tobacco products?

In past 12 months?

Height: ______________

Yes

Yes

No

No

Weight: _____________

Type: ______________________________

How much? __________________________

Have you previously been declined for life insurance?

Yes

No

Reason for decline: _________________________________________________________________________________

Are you receiving Worker¡¯s Compensation/Disability?

Yes

No

Reason for the Disability: ____________________________________________________________________________

Type of Disability Income: __________________________________________________________________________

Actively working?

Yes

No If no, please explain? ________________________________

____________________________________________________________________________________

Does the client have any family history (parent, sibling) of death before age 70 due to cardiovascular, cerebral

vascular disease, diabetes, or cancer?

If yes, please explain: ____________________________________________________________________________

_________________________________________________________________________________________________

Within the last 5 years has the client had a moving violation, reckless driving, or DUI/DWI?

If yes, please explain: ____________________________________________________________________________

_________________________________________________________________________________________________

Any prior convictions? If so, please explain:_____________________________________________

_________________________________________________________________________________

Does the client participate in any dangerous activities/avocations (scuba diving, racing, skydiving, etc)?

If yes, please explain: ____________________________________________________________________________________

__________________________________________________________________________________________________

Is the client intending to travel to any foreign country (excluding Canada)?

If yes, please explain including length of stay: _____________________________________________________

__________________________________________________________________________________________________

U.S. Citizen? Yes? No?

Phone: 888-227-3131 ext. 600

Green Card? Yes? No?



Applying for Citizenship? Yes? No?

Fax: 215-233-3683

TO BE ABLE TO GIVE YOU ACCURATE INFORMATION IT IS IMPORTANT THAT WE RECEIVE ALL FORMS BACK.

List all prescription medications taken over the past 12 months.

1. Medication:____________________ Amount_____:____________ Currently Taking?____________

How Long Taking:________________ Reason Prescribed:____________________________________

2. Medication:____________________ Amount_____:____________ Currently Taking?____________

How Long Taking:________________ Reason Prescribed:____________________________________

3. Medication:____________________ Amount_____:____________ Currently Taking?____________

How Long Taking:________________ Reason Prescribed:____________________________________

4. Medication:____________________ Amount_____:____________ Currently Taking?____________

How Long Taking:________________ Reason Prescribed:____________________________________

5. Medication:____________________ Amount_____:____________ Currently Taking?____________

How Long Taking:________________ Reason Prescribed:____________________________________

Have you ever been diagnosed by a licensed physician as having any of the following conditions?

(Circle all that apply)

Yes

AIDS/HIV Positive

Alzheimer¡¯s Disease

Cancer (type)

COPD (emphysema)

Strokes

Coronary Artery Disease

Multiple Sclerosis

Crohn¡¯s Disease

Depression/Anxiety

Diabetes (type)

No

If yes, please fill out third page.

Parkinson¡¯s Disease

Alcohol Abuse

Drug Abuse

Epilepsy (type & date of last)

Cirrhosis

Asthma

Hepatitis (type)

Irregular Heart Rate/ Palpitations

Kidney Disease/Failure

Lupus (type)

Peripheral Vascular Disease

Rheumatoid Arthritis

Sleep Apnea

High Blood Pressure (readings)

High Cholesterol (controlled)

Heart Attack

Aneurysm (location, size,

operated?)

Organ Transplants (type)

Cardiovascular Disease

If you answered ¡°YES¡± to any of the previous questions, provide full details here.

Diagnosis: __________________________________________ Date: _____________________________________

Treatments: _________________________________________ Prognosis: _________________________________

Medications: ____________________________________________________________________________________

Diagnosis: ___________________________________________ Date: _____________________________________

Treatments: __________________________________________ Prognosis: _________________________________

Medications:_____________________________________________________________________________________

Give details on any surgery or procedure. (i.e., angioplasty, bypass surgery, pacemaker, defibrillator)

Procedure: ___________________________________________ Date: __________________________________

Treatment or Therapy:___________________________________________________________________________ Residual

Problems: _____________________________________________________________________________________

List additional medications, diagnosis, or procedures

on a separate page and attach to this document.

Phone: 888-227-3131 ext. 600



Fax: 215-233-3683

Typical Health Concerns and Medications

for Life Insurance Prospects

Asthma

1. Frequency of attacks or hospitalizations?

2. Any oral steroids including inhalers that are

steroidal?

3. Smoker?

4. Stable pulmonary function tests?

5. Any diagnosis of COPD or emphysema?

6. How long diagnosed?

Cancer

1. Where cancer originated?

2. What stage of cancer, 1-4? 4 being

metastasis and uninsurable.

3.

What kind of treatment and last date of

treatment, if fully recovered (including

surgery, radiation or chemotherapy?

4.

5.

6.

When diagnosed?

PSA for prostate cancer ................
................

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